Episode 256: Childhood Apraxia of Speech Demystified with Alonna Bondar, M.S. CCC-SLP

Hi and welcome to episode 256 of the Untethered Podcast. Today we have Alana Bondar joining us. Alana is a pediatric speech language pathologist with over 24 years of experience. She specializes in apraxia and other speech sound disorders. She enjoys working with children with a variety of diagnoses, especially children with down syndrome and autism. She's PROMPT certified and uses PROMPT along with DTTC to facilitate verbal language. She works collaboratively with the child's school SLP to optimize results.

Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider.

Welcome to the Untethered Podcast.

I am your host, Hallie Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway tether, dural tissue and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019. Thanks for being a loyal listener.

As we jump into today's episode, remember.

To listen with correct coral rest posture, tongue up, lips closed, teeth apart, breathe through your nose. Let's get started.

Alana, welcome back to the podcast.

Thank you so much. Glad to be here.

I know last time we were talking a bit about your journey and today we're going to be talking about all things childhood apraxia of speech. So I'm going to turn it over to you, but I think it would be really helpful to dive into just a quick explanation of like, what is childhood apraxia of speech? And like how is that different from a speech sound disorder or an articulation disorder?

Okay, so firstly, I just want to mention all speech is motor. You know, when it comes to speech, whether we're talking articulation therapy, even phonology, when we're talking about, you know, fronting versus backing, which a lot of therapists are familiar with, we need to make sure that the child understands how to make the movement. Okay, so there is some overlap in that. But the difference with childhood apraxia speech is that it's called a movement disorder. So it's the planning and programming of the movements. So very often, and I'll go into that in a moment. But very often children will have a large repertoire of sounds, but they have difficulty moving between the sounds and connecting those sounds for intelligible speech. So they may have a lot of segmented speech, or they may leave off initial or final sounds where it's not a phonological pattern, but rather that they just can't go from that initial sound into the next sound and into the next sound. So what we want to look at is we're looking at a planning and programming disorder. So the child needs to plan out what articulators need to move. But then there's the force, the tension, the speed that they're moving in, and that is the programming part. So somewhere along the line, something is getting disconnected. So sometimes the jaw height is too wide, their mouth is open over here when they need to be over here, or vice versa, or they're not rounding their lips when they need to be rounding. A lot of kids speak like puppet like speech, and they don't know how to move those dissociative movements to get the sounds that we need to connect speech together. So that's the gist of it. Okay. And then if you think about it, when we're doing articulation therapy, we are instructing the children how to move their articulators, but these children don't have trouble generally connecting the sounds. And actually, if you do find that the child does have trouble, and I've seen that with my arctic kids, you know, the things that I'm going to be talking about today, as far as principles of motor learning and therapy for apraxia, keep in mind, again, all speech is motor. And you might want to go back to some of these techniques for your. What we think is an artichoke that just has trouble really. You know, they can do well with, let's say, neutral sounds where the jaw is really high. And then when it comes to a diphthong, and they have to go down and then back up again and retract, and they just can't get all those movements together. Think about how that relates to motor planning and try to use some principles of motor learning with your maybe traditional Rtech case.

So, yeah, well, and we just. I just recorded an episode that they heard Last Week with Dr. Jen Moore where we talked quite a bit about jaw heights and grading. And, you know, she alluded to the principles of motor learning and that as well. For someone who's new to this space, will you explain what you mean by principles of motor learning? Because this is not one of your typical terms that I think is commonly.

Taught in grad school. Sure, sure. Definitely not. And that we could. We could mention that for a moment, Hallie, that a lot of therapists, you know, feel frustrated and maybe a little kind of annoyed at themselves for not understanding apraxia more. But I don't know about you, but I learned maybe that much. No, maybe that much. We learned that it was a term. And I remember when I first started out in early intervention. That's my background, early intervention. I actually worked as a case manager and then became a therapist and my mentor. When I was having difficulty with one of my little ones, she said, well, maybe it's childhood apraxia of speech. So I kind of heard the term and I started digging, going down that rabbit hole. And it's a big rabbit hole. And here I am today with really a really good understanding of what it is. And so let's discuss principles of motor learning. So when you have your traditional language therapy case, and a lot of our EI kids are like that, they just delayed in their language. And we're going to use a play based, you know, kind of whatever words come up in the session. We may have a target word list like mama and dada, you know, toy book. But when it comes to apraxia, therapy needs to be really structured. So number one, the principles of motor learning is the structure in which we practice. So the practice conditions what we call them. So are we going to practice the word in what we call constant blocked practice, which means the same word over and over again, perhaps 20 times in a row, 30 times in a row in a block? Are we going to practice it in more variable practice, where we'll do 5 of this word and then maybe 5 of another word, or perhaps even 1, 1, 1, 1? Are we going to keep the vowels really constant? Like we're only going to choose two vowels to practice rather than, you know, picking a number of different vowels. So we're going to keep the practice really constant. In the beginning of therapy, when a child first comes to you and they have a very limited number of sounds, we're practicing the words constant block practice. That's one part of the structure. Because we want them to be successful. We want it to be something they can carry over and generalize. We'll discuss that. And so we want to keep it constant and block. However, for generalization, variable practice is really important. One of my clients, the mom, told me that the child is having trouble reading in school, which we know that these children have reading difficulties because the teacher is going through the P, initial, P, initial P words, but with all the different vowels and he can switch off between the different vowels. Of course, I'm going to work on that and we're going to practice it together. But at some point during therapy, we do have to make it a little more challenging so that the generalization kicks in. Okay. That's one part of Principles of Motor Learning. A very important part of principles of Motor Learning is multisensory cueing. And by the way, if you want, we can link in the show notes, we can link to a research article on principles of motor learning. So remind me and I'll send that to you. And we can definitely link to that because, you know, it's great to go back to the source. Well, this is information and then take it further. You know, in fact, anything I reference today, I'll send you the articles. Okay, so when we talk about principal principles of Motor Learning throughout the constant block practice or the variable practice, we want to use multisensory queuing. That's how it differs from a language based approach. And this is really key because our kiddos need you to really. And, and this is going to vary between children. So we have to have all the cues and then figure out what that child needs and even what that child needs for that particular movement pattern or that particular structure of the word. So I have my sound cue cards, I have my hand cues, right? I'm going like for those of you who are watching on the video, it's like, or I might do M or M and I'll have my cue cards. I might say watch my lips. So it's combined with those auditory verbal cues. So it's not just pointing to my list, but I might say watch how my lips are rounding, right? Watch how I make a circle. And so giving them the auditory, verbal, visual. And then of course, as you know, you spoke with Jen about a lot prompt. A large part of prompt is using tactile cueing and so really getting on their face. I happen to be prompt certified, so I do use that with a lot of my kiddos. Combining approaches. PROMPT is an evidence based approach treatment for apraxia speech as well as DTTC and dttc. It stands for dynamic temporal and tactile cueing. Do you want me to go into a little bit about DTCC or.

Yeah, you can share a little bit about that for those who are new to that.

So as you spoke with Jen about all about prompts, I won't spend too much time on that. But we Use it. There's a cognitive linguistic component, a social emotional component and a physical sensory domain. So we combine all that when we're working with our children. Dttc, which is a very widely used treatment, evidence based treatment approach for apraxia of speech, and I'll send you the article on that, relies on what we call a temporal hierarchy. So we want to start off by giving the child the most support, which is called simultaneous production. So saying the word together with the child, we're going to say, say it with me, watch me, let's do it together in a very slow rate. So we want them to move, we're going to help them move very carefully through the sounds in the word. And then we want to have the child start taking more like as we say, ownership of the movement and not give them so much cueing. So we might. We were starting to work on more normal rate of speech. So not so slow. We're still saying it together, but a little faster, normalizing the rate. And then we're doing imitation. I say it, you say it. And then there's called delayed imitation. I'm going to put out a video on that this week on my Instagram. But that's really, really important for generalization because it says, I'm going to say it. And now you wait, right? Don't say it yet. And now you say it. So the child really has to think about the movement before they produce it. And very often we see children, they can do it in therapy, but they have difficulty generalizing it. The mom will say, well, it's great, I see the videos coming from you. But at home it's now, I will say it takes children time to generalize, but if they're really taking too much time, look back at your practice with them. How much are you helping them versus trying to fade those cues and have them take ownership of the movement, you know, and then of course the spontaneous production. So that's the temporal hierarchy, which is crucial, you know, and that along with prompt. So people always ask me, well, do you use prompt? Do you use dttc? I use both. Both. They combine beautifully. And of course, you know, some children really don't want you on their face and that's fine. You know, some kids, you know, they can use a little joy. I might just go in with some, what we call parameter support. Just holding the jaw like this and keeping it from going to those really low boundaries when they don't need to be right or just helping them round their lips. And any therapist can go in there. I mean, I didn't need the prompt certification to tell me that if we want to get children to round their lips, go on their face and help them, right, we can all do that. We can all come in and do that. It's also about really supporting the jaw so that the lips can dissociate. So keep that in mind. Also it's like this middle finger is like supporting the jaw, rounding the lips so that you're dissociating the movements, you know, so that's, I guess principles of learning, motor learning in a nutshell. Of course, it's an hour lesson in my course, so there's way more than that. But the article will, yeah, the article will give you more information. But just so you know it, that's how it differs. You know, we must make sure that we're really narrowing down the target word list to sounds that they're stimulable for and combining them into words, practicing it in a structured practice with multisensory cueing like that. Those are the highlights to.

No, I love that. And I want to like jump further into just like the term of childhood proxy of speech too because I feel like that in and of itself is something that is wildly misunderstood. I think there's a lot of misinformation out there. I also, you know, I grew up, I grew up, I evolved as a therapist early on in my career actually hearing and being told that this was over diagnosed and that was kind of like the catch all diagnosis for so many children. And you know, I don't know where it stands today, to be honest with you, because being in the MYO world I think that we very quickly, you know, we know how to differentially diagnose and we know if there's more going on than just an orofacial myofunctional disorder. And you know, obviously if we're not somebody who can treat it, on my team, we're going to have somebody who is trained, you know, whether it's in DTDC or Prompt or someone who works with children with apraxia, they're going to step in right where they're going to co treat or they're going to take over the case. I do have some people on my team who, who treat cis. But all that said, I want to dive into a few things. One being what is it? Why do some children have suspected childhood apraxia of speech and why are they not going like right into a diagnosis which I know is a whole other rabbit hole? So I'll turn that over to you.

Yes, yes, yes, this is great questions and I was definitely planning on covering that today. I also want to mention I am trained in orofacial myofunctional therapy and I do see kids often with both. So we can discuss that for a minute and then discuss like, you know, I mentioned, you know, on my Instagram platform like don't use oral motor exercises for children with childhood apraxia speech. And there's a lot of misconception. Well, that's another whole topic, you know, or you know, oral motor exercises versus myofunctional exercises. And that's another conversation which I'm sure you've gone into on your, in your podcast and we not going to discuss that. But just to say that there could be children that have comorbidities. So yes, we have children with just childhood apraxia speech and I have those. I do service a lot of children that have comorbidities, whether they have autism, whether they have, you know, other genetic disorders, certainly down syndrome. There's a high, high percentage of children with down syndrome and autism that have apraxia of speech. So that's something to keep in mind for anybody listening to this podcast. The numbers are somewhere in the balance of like 60, 70% is high. So consider that as a comorbidity to whatever you're treating. And yes, it certainly is possible for a child who has down syndrome to need some oral motor, some possibly myofunctional exercises. Chances are the anatomy. These children have high narrow palates. They have other things going on. We often see that forward tongue movement. And I know my friend Dina Zagwe works with children with down syndrome with orofacial myofunctional disorders and she's had tremendous success with them, amazing success. So there's definitely room to consider multiple diagnosis for children. So let's put that out there because I get a lot of questions about that. But if a child just has just. But a solid diagnosis, just. It's not a just. But you know, that's the only diagnosis a child has. Please do not use oral motor exercises. Okay. We can use things like a whistle or things like a popsicle stick. If the child needs. If the child has non verbal oral apraxia. Let's talk about that for a moment. They just have difficulty even understanding following directions. When it comes to round your lips, close your lips, right? You open your door small. Some children really don't understand that. I actually had a child I was working with for articulation and I was shocked. I asked him to stick out his tongue he was a child in regular mainstream school, seven years old. He looked at me like I had two heads. He did not. He just. And I said, why doesn't he. Why can't. He still got his time? So I took a. A popsicle stick, I put it over here, and I said, can you touch the stick? Sure, no problem. You know, that gave him a cue. So it's okay to use a cue if you need to teach the movement. It's okay if a child doesn't understand close your lips, but when you put a little post it note or a little popsicle stick between their lips, now they understand close lips. Sure, you can do that. But we're not looking to hold. Hold the stick between the lips for a certain amount of seconds, minutes. We're not looking for, you know, endurance and strength exercises. We're looking to improve the movement and for them to understand the movement direction. So keep that in mind because I get a lot of questions every time I post those, you know, kitschy reels that say don't use oral motor. They go, what about if I'm using it for placement? Yes, yes, absolutely. I do that. And I actually have a video that I want to post about that. That's fine. So just keep in mind if we're just using it like for that momentary cue and then we're removing it and, you know, as long as it takes for the child to understand. And I've used that from time to time when needed. Okay, so now that that's out of the way. So let's get to talking about suspected apraxia of speech. And it's always a question that I get parents asking me, when it can be diagnosed, how is it diagnosed? I was told that my child cannot be diagnosed before the three years of age. I was told that that's the big one, the big myth, the age. You've heard it many times too, I'm sure, and your team has heard it. And the reason why that comes, I mean, I don't know if it was said in some literature somewhere, but that's a myth. Some people might have that as a kind of time frame, because that might be the time frame that a child might be able to sit with greater attention and attend to cueing and sit through maybe perhaps a standardized test. Right. But I've had children in my office that come to me at two and a half that have amazing attention. And I've had children come to me at seven that are, no, no, can't get through it for anything. Okay, so the age thing really bothers me because it has nothing to do with age and everything to do with the ability to participate in what's called a dynamic speech motor assessment. And what that means. Dynamic means that we ask them to imitate some movement pattern through a word like we asked them to imitate. Let's just say we start with simple consonant, vowel, vowel, consonant words like me or up, and then we go along the continuum to bisyllabic words and other multisyllabic words. And if the child cannot imitate it, then we provide multisensory cueing and we help them to, you know, to produce that sound with more accurate movement patterns. Now, they have to be able. This is the key to attempt imitation. Because a lot of people will say, well, my child doesn't imitate words. Can they attempt it? Will they sit and try? And most of the time, parents are not aware that that's something that a lot of kids can do, some kids can't. But we help them at least attempt it. And when they attempt it and we help them and we try to produce it better. Number one, it shows us that it will highlight the discriminative characteristics of CAs, which I will discuss in a moment. I realize we didn't discuss how does it differ from other disorders besides that it's a movement disorder? Number one, it will highlight the discriminative characteristics. Number two, it shows us, is this child ready? Where are they as far as being able to participate in this kind of therapy? Do they need other work, precursor work, which we can discuss? What is their sound repertoire like? How limited is it? What are their vowels look like, the vowel distortions, which is a highly discriminative characteristic. So until we really get them into that dynamic motor assessment, we won't know that information. So while, yes, it's true that. So let's discuss suspected. Right. So what happens when we. I get a call from a mom, the child's 18 months old, I mean, with very few sounds, likely they're not going to participate in a dynamic motor assessment. And this is the key. Also likely, they haven't been receiving traditional language based therapy for any length of time. And that's where we look at whether or not we can even suspect it. I've had parents literally call me saying they just signed up with the early intervention program and they think their child has apraxia. You know, I mean, wait, at 19.

Months ago, we go with that, right? You're like, based on what?

Yeah, it may be that this child will end up with that, right? Yeah, but we Wouldn't jump to that conclusion right away before at least a child. And it's not a specific number, but I usually go in a round of like six to nine months. Even children that are receiving a traditional language based approach need a little time. Yeah, it's not like this magic wand that we go in there. I did many years of early intervention. Some kids would pick up really quickly. Some kids, you know, needed like six, nine months. So we want to see them at least receiving treatment, traditional treatment, for some length of time. And then when usually it's the therapist that's treating that child, you know, through the early intervention program that says, you know, I'm kind of like, I've broken out all the things I know how to do and I'm not really getting anywhere. And I get most of my referrals.

That way, you know, and that's like the accepted CAs, like, well, yeah, and.

Then we have this conversation with therapist and usually will tell me this is what I've done, you know, and then as you say, look, I've tried some cueing because I have a little background. Maybe they took prom training, maybe they, you know, took the DTTC training online. They have something most therapists are aware, but they say, look, I just don't know enough, certainly not to make that diagnosis. And, you know, and they send them to me. So, you know, that's the key is like, well, what have you already done? And then of course it comes down to, well, what will it take for that parent to get therapy with a therapist that's trained in apraxia? And for some parents, that's easier. And they'll say, well, I don't really care. Yeah, right. Well, for some parents, they'll say, look, you know, I don't care if you even suspect it or not. My kid's not making progress. I want to come to you regardless. I've heard, you know, you have lots of years of experience and I don't care. And I'll make it very clear I'm not making that diagnosis. If you'd like me to treat your child with multisensory cueing, with principles of motor learning, absolutely, we'll go there. But I'm not making that diagnosis yet. Right. And usually if parents can afford the private therapy and they live, you know, relatively close to me and they're work schedule allows, you know, the various factors because I only work in my office. So there are various factors involved. So if they can, they come because there's no downside.

Right?

Right. There is no downside. To treating a child with principles of motor learning. Even if you don't make that official diagnosis. And if I. If you remember nothing else from today's podcast, remember that one? Remember that one. That's key. Because a child with a language delay, Right. If you treat them with principles of motor learning and they like, make this incredible progress in a couple of months, and you're like, well, it wasn't really apraxia. Okay, they made progress anyway.

Right? Exactly.

Yeah. You know, but we don't want to see that child who's 5 years old. I got a call, I did a consultation with a clinician the other day. She started with a child 5 years old in school in September. And he's practically unintelligible. At least was then she's making progress with him and she's like, it's just so sad. Is lots of vowel distortions, groping behaviors. Well, let's. Let's go through the discriminative characteristics, you know, these children. And very carefully, let's discuss, before I even go into that, the fact that I get a lot of comments. Well, the child is consistent with their productions. A child who has not been challenged to produce new motor plans, if that child has 10 words in their vocabulary, even if it's produced incorrectly, it will be very consistent because they practice those words over and over and over again. So consistency without a motor speech assessment, you know, it doesn't apply. I could show you an assessment I did recently with the dems. You. You have to ask the child to repeat the word three times. Each production was different. I want to tell you, four months later, I redid the test and almost every word was correct.

Wow.

Four months later of twice a week therapy with parent carryover, and almost every word on the DEMS is correct. He has a ways to go. I'm not going to tell you he doesn't have a lot to work on, but just imitating single words, tremendous progress. So we're going to see when you challenge a child to produce new motor movement, you maybe. And these are the discriminative characteristics. Groping and trial and error behavior. So they're going to try to reduce the word. But you might see them like really being challenged with the movement. Okay. Vowel distortions. That's a real highlight. So instead of saying this is a. I'll give you a few that I hear all the time. Instead of saying bed, like the vowel, they'll say bodies. Again, a neutral vowel is taken to lower jaw. So bod. Instead of saying ih. Very neutral vowel. Everybody Say it while you're listening. It becomes e. Instead of it, they say eat. This is a big one. And then of course, your diphthongs. A diphthong is two vowels that are combined together. For those of you who are listening, that may be parents. If you have a vowel such as ow in the word found or out, it's an ah and an u. So now the child is crossing two planes of movement. The jaw has to go down, come back up and round the lips. So what will happen? They simplify it to the first vowel. So out will become at, found will become fanned often. Okay, so when you challenge a Todd to say the word out and they say at, that's a diphthong. That's a distortion. Right? They're simplifying the movements. And then you can, in the assessment, you're like, can you say ooh? Right? The child says ooh. And then let's do it slowly together. Watch me. Right? And we do ah. And now you tell the child, we're going to come back up, we're going to round our lips and you give them all the cueing. And it's like, sometimes it's like magic. And the mom is sitting there going, whoa. Okay. You know, and then when they ask me if I can, if I can diagnose apraxia, maybe I can, maybe I can. I'm like, now that you see how powerful the cueing was, does it really matter at this point in time? Right, right. And this is what I want to get across. But let's go through more discriminative characteristics. So we have prosody errors, which is the intonation pattern. So when we're speaking together, my voice is going up, my voice is going down. These children have more robotic speech. But more importantly, they usually put the stress, they don't put the stress in the correct syllable of the word. And this therapist that was having the consultation with me the other day, it was interesting. We were going through some of those two syllable words and it was just, if you say a word like, I'm trying to remember one of those words instead of bottle. So it says don't say bottle. It's not bottle, it's bottle. And also, we don't say toll, we say dole. But that's right. It really affects intelligibility in a, in a sentence. Highly does. We're not expecting someone to say batol. We're like, what's bartol? Our brain doesn't even translate that word. Yeah, we don't even. We don't Even know what that word means. Right. Then inconsistent voicing errors. So instead of producing a sound that requires vocal fold vibration, like a B sound or, you know, or a G, they'll produce a K instead of a G. I get a lot of PB errors. A lot. They'll use. They'll say ub for up. It could be for many reasons. But one thing I didn't mention in the beginning, Apraxia. Children with apraxia have to combine a lot of the subsystems of language, of the movement. So you might have discussed that with Jen. You know, we have respiration, phonation. So they're, you know, resonation. How it's. The sound is produced in the mouth versus nasal. So a lot of kids might substitute nasal sound versus, you know, an oral sound. But the PB also might be because they're just pressing their lips together too much. Again, that timing. They don't have that light movement of the lips. It's rough. Or the opposite way where it's like bouncing too much and not holding together firmly. So that's something we have to work on. The intrusive schwa. That's a biggie. I was evaluating a child yesterday, actually. Mom is an slp, and we're having. And just chit chatting with the child. He has conversational speech. And I'm listening, and he's going. He's adding in the sound after Ds. Typically, we hear it after what's called a stop sound. So after your Ds, after your GS, they'll say like, big. A bigger, you know, head. Head. He was adding them after wives, which sometimes we have. They'll say mamia. They might even put it in the middle of a word. I had a child say instead of the Paw Patrol character, Marshall, he would say, mara, show. And I was like, what'd you say? You know, I don't even know what he said. Really, really distort speech. Marshall. What's Marshall? Marshall. Oh, Marshall. Right. So we have to try to say please. We spelled a. Trying to interpret kids speech. And it's really fun. But it's martial, right? Move. Move with your hand. Move with the word. So that's that movement. Don't take that break in the middle. Keep going, keep going. You know, and that's, I would say, probably one of the things that comes out most unnoticed by clinicians, parents, that schwa. Because sometimes it's pretty subtle. It's not so strong. I will say. And here's where I. One of my. I was telling Hallie before we started recording. I try to be very positive about my recommendations, but there are a couple things that I say please don't do. One of them I mentioned before, oral motor exercises. The second thing is, I beg you, please do not bounce sounds. We don't teach the child. G, G, G, go. First of all, I see no reason. I don't care what you're treating the child for. I don't see any reason to say, go, go, go, go. Maybe, and I'll give it this Maybe for some phonological awareness approach, there might be a treatment. I don't know, but it's, you know. Now, g doesn't stretch, so it's a tough one. We try to move through the vowel, but go right. We give a lot of visual cues. Pointing, and it's a back sound. Right. Ball. I can't tell you how many times I've been. When I used to treat in daycare centers, and I would hear someone in the next room bouncing ball like, buh, buh, buh, buh, ball. And I please don't do that. You know, please. Because it's all about the movement, and it creates that schwa the same if it's at the end of a word when we. When we say to our child, it's. It. Watch. It's big. Be careful. Better to, like, almost leave the sound off than to highlight it. And we really stay away from those stop sounds in the beginning of therapy because they're trouble, you know, Watch out for them. If you can pick other words, pick s. Right.

Yeah. So it's fascinating, though, because I feel like in grad school, like, I can think back to where it was like, drill, drill, drill, repeat, repeat, repeat. So it's almost like you're trained to be, like, in isolation and then to attach it to the word. But then I also feel like that schwa getting added in was almost like, oh, it's okay. Teach them to overcompensate, and then we'll backtrack. Like, it was almost how I was taught, which in theory and in practice, it doesn't actually make sense, especially for certain populations, like, you know, apraxia being one of them. But really, in general, you know, I remember early on, like, kids going like, ba, ba, ba, ba, ba, ball. And going ball. And actually. And I'd be like, oh, no, we created that. We have to undo that. Like, I remember that very early on being like, I don't know how to do arctic therapy. They did not teach me this school and kind of figuring it out. But as you're saying this, I'm like thinking back to some of my earlier patients, even where I had some of these patterns that I also feel like I created. Like they were not all present. At least, you know, maybe they were and they didn't come out at the beginning. But I definitely helped reinforce those patterns that we were trying to change. So it's a great.

Unfortunately, those kids get sent to me.

And then live and learn.

So it's. I have actually some free handouts about these things. I have what's called a target selection handout. So if anybody joins my Instagram, it's one of the first pinned posts that I have. You can sign up for that. And one of the rules is don't bounce sounds. There's a lot of do's. I give you lots of do's. So I'll help you to plan the treatment, at least initially. The target selection, how you plan it, discussing a little queuing. But don't bounce sounds because it just. The primary reason, forget about having to undo it, is it just doesn't help your client. If it's a movement issue, it's not functional. If it's a movement issue, let's move now. With that said, and that's on the target selection handout too. Try to choose sounds that have more movement. We don't use a developmental hierarchy when we choose our sounds. And unfortunately, this is like a myth. It's like, no, that's for a language based approach. But I've had kids that I work with that can produce an S, an F, which what we call later developing sounds. Okay, those are fabulous. They're what we call continuing sounds. They have so much movement. And guess what? S is one of the most common consonants in the English language. Yeah. So to me, that's like, yes, we can do an S. I just said yes.

For me, like, early on, when I. I think when I was starting to learn about principles of motor learning and I was also like, learning about just different approaches to target selection. I remember somebody, I don't remember who taught me this, but I remember either reading or being told, you know, you don't have to basically follow the order. Order of like, sound development in your therapy target selection. I was like, I mean, that makes sense. Like, it was like, I'm like, oh, huh, okay, that's pretty freeing.

And.

And that also kind of went in line with just how I thought as a therapist. Like, what are the child's strengths? What are their weaknesses? What can they do? Can we build on that? Like, can we build on what they're really good at, what they're gonna feel successful with, and kind of go from there. And so I feel like it almost gave me permission to do what I kind of felt was natural.

Yes. And I want to tell you, you just hit something so important for a couple of things. So first of all, back to just the continuing sounds for a moment. When we're working on continuing sounds, there's so much movement, so you can easily go to work on the word see, right. Find. So great. So great. You can build so many words around that. You're so right. You're. Now, what I wanted to mention, because you said, oh, you know, working on this kind of, like, hierarchy. You know what else you don't have to do, Hallie? You don't have to work on words in sounds in initial position either. If the child can do it in final position. I just put out a reel about this, and I got so many questions. The child is not stimulable for S in the initial position of the word. You know why? Because she substitutes it for a K. Should I tell you why she substitutes it for a K? Kids are so funny. This is great. Think about this. So she's producing a stop sound, but she doesn't have the T she backs, which is, by the way, not necessarily a normal pattern. But that's another story. I work with a lot of kids who back.

I know you're saying this, and I'm, like, doing it in my head. I'm going, what does this matter?

Look what a phonological system did. It's fabulous. It's so great. So I'm such a nerd. But she went. Instead of saying C, she says key. And boy, that motor plan is so solidified in her brain. So I'm trying to work on C, and she's like, no, key, by the way. I have started to just throw it.

In a little bit.

I have these, like, keys in my office that go into a door next door, and I just pull out. I'm like, key. And she's starting to get it, but she has a lot of comorbidities. So cognitively, you know, she's not up, you know, to where some kids would be at that age and understanding that minimal pair. But, you know, sometimes we have to create our own minimal pairs, and I'm just introducing it. But you know what? She can do the word ice for.

Ice cream so she can make the sound.

You know why? Because I'll tell you something else. This is also great. Just had a discussion about this with Somebody, she omits the final sound rather than substitute it. So instead of ice, she won't say ike. She'll say I. It's so much easier to add a sound than to change a sound that they've already created another sound with another word. Instead of saying ki, she's saying see? Instead of saying saba for her grandfather. It's a Hebrew word for grandfather. She says, not even Kaaba, she says baba. Because that was from a very young age where she was just reduplicating the syllable and forget it. I'm taking out the picture of Saba. I'm trying. She's like, please, lady, it's Baba. I don't know what you're talking about. You know, it's not gonna.

Why don't you hear me?

Like you don't know what you're talking about? I once had an argument with a child about the. About the word peppa for peppa pig. And he's like, pepe. Pepe. Now, I understand there's a British production of it. I got that. But still, it wasn't right. This. The distress. Remember we discussed before the stress on which syllable? And I'm like, pepe. And he's insisting it's pepe. And I'm like, no, it's not. It's pepper. Like, no, you know, And I had to really do some reteaching on that one. But why start with something they can't do? As you just said before, work with their strengths. Our dynamic motor speech assessment is all about finding their strengths. What can this child do when we write our report? Part of the prognosis that we put into the report. How do we determine prognosis? How well did they do in that motor speech assessment in terms of being able to attend to cueing? How successful were you when you gave them the cueing? What is the support at home in terms of carryover? In terms of maybe other therapists working with this child? And again, how stimulable are they? We're not going to work on sounds they can't do. You're wasting your precious therapy time, I guarantee you. And I already see the change because I worked on words like peace. Yes. Ice. There's one more now, I think those are the main three words that I worked on, so common in play. And now she's starting to understand we can put that sound somewhere else. And it's like, how? Right? Take what they have and we can discuss more about assessment. Especially for those little kids. We can go into that, like, what do I do with that? Two year old, Two and a half. Generally they're like two and a half when they come in. The therapist has been there for, like, again, nine months, a year. And so are they going to sit for a lengthy assessment? Probably not. They have a very limited phonetic repertoire. Anyway, is it really important for me to sit with the dems? And the DEMS is a Criterion reference test that's widely used, created by Dr. Edith Strand, who is, you know, obviously, if you know anything about dttc, she created dttc. She is like a mentor to all of us in this field. I was so grateful to meet her when I went to NYU for the advanced workshop. I. I fangirled with her for a little bit. I literally stopped her in the middle of eating her breakfast and I said, I need a picture with you. I was like, please forgive me, but I need. And it was really funny. But she's amazing and you should eat up anything you can get your hands on. I will send the articles to Hallie. Read everything, because she knows her stuff. 50 years, she just celebrated working in this field. And so her test is obviously the gold standard, the go to. I use it with a lot of children and I will even attempt it on those little guys. Most of the time they come in, like, you could just see how nervously I'm looking at my door. You know, you could see them coming down the stairs and just like, they're, like, practically shaking because they think they're going to a doctor's office. You know, it's so, so sad. And I try to make them feel at ease. And I got all the toys. We're sitting on the floor, you know, doing all the things. And sometimes halfway through, I'll, you know, come to the chair and try to do more, you know, structured work. But many times we can't. And chances are that child is coming back to me anyway. And so I can revisit that at a later time. But what I do is I play with the child with their preferred toys. And I ask the parent before they come in on my intake form, this is a really good question. What does your child like to play with? If you don't have that there, put it there. Because, boy, is it incredible when you have the exact toy the kid likes and they're like, you could see their eyes going, how did she know that? What? She knows I like Paw Patrol. She has Paw Patrol too. Like, wow. And like, it's right. It's the best. It's so great. And so right away, they're like, put at ease because they See those toys sitting on the floor? So you're like ready to rock and roll. And then you're going to probe the sounds or the words and. Or that the mother already reported to you before they came in that they can say. Because you're not going to take the mother's word for. Not that we don't believe them. We believe them, but we want to hear the way it's produced. Because their mother doesn't notice those vowel distortions because they know what the child's saying. If the child says they want to go to bed, they know the child is saying they want to go to bed. So when the mother reports to you that the child can say bed, she's right. Language wise, the child is saying bed. I'm sure it's consistent every single time. It's a perfect example of a word approximation. Right? It's not even. That's the child's production of bed. So when you point out to the mother that, hey, the child is the story in that family, like, oh, or you know, what the parents say before they come in? Sounds like my child has an accent. That is very common because when they distort the vowels, it sounds like they have an accent. So. And when we ask them again to repeat those words, we will hear those distortions. Okay, so you want to probe the words that you, the parent has reported to you beforehand. I ask them, can your child say any words? What sounds can they produce? What sounds do they have trouble with? You know, you have that information before, and it's like on a piece of paper right next to me. So I'm going to. And then what I do is I take those sounds. If the mother tells me the child says e M, the B sound, I don't know, you know, and let's say ah. Can the child say ma? Can the child say me? Right. Can the child say um? So you want to take those sounds, mix them up into simple, perhaps not so simple, you know, vowel, consonant, consonant, vowel. You know, vowel, consonant, vowel, consonant. So different syllable structures. And where. What can that child do for you with the sounds they already have? Because again, we're starting where they are. What do they have? Okay. And by the way, all of the information that you're getting in your assessment, you're already planning a treatment. You're planning a treatment. It's all there. Your first session is, like, done right? When you're done with your assessment, because you know what, they were successful within the assessment, and you're going to go straight there. And then you're going to probe some sounds that are not in the child's repertoire. Everyday repertoire. Right. Can the child make other sounds? If you give them some cueing. And then it's almost like also this, like, the mom is like, oh, this woman has a magic wand in that, you know, little toy box over there, you know, and it's like, sometimes it's just like, I didn't know we could say that. And it's like, yeah, it's great. And I make a joke. I'm like, yeah, it's my magic wand. What can I do? You know? Or, you know, and then, you know, write down the cueing the child related to the most. You know, they seem to do really well with those cue cards. Like, they related really well. Or when I got on their face, that was like, that was it. Right? Like, what did they. And this is just like, first lesson, you know, first session information. Obviously, it's going to get more detail than that, but you already have a direction where you're going to go for that first session, you know, so do you need more information? Yeah, you know, does the Dems give you more information? Absolutely. It was created for a reason. You know, it's. It's fabulous. But not also when, you know, when I went to the advanced workshop at NYU, Dr. Strand said, not everybody has access to that test. It's not cheap. Some people work in a school district. They don't have the funds to buy new tests. It's okay. She herself said, it's okay. Make sure that you're looking at a wide range of. Of, you know, vowels, vowel and consonant combination. Sit down and make up a list. Right. There are lots of TPT products. I know Rebecca from Adventures in Speech Pathology has like, a syllable. Forget what it's called. Look up syllable. But she has. For every consonant, there will be, you know, an initial position, final position, like up, pop, PI, you know, just different shapes with those sounds. And you can take out something simple like that. Just make sure you're testing the different sounds and different combinations and really taxing their motor system to see the breakdown. You see the strength, see the breakdown. You know, where are we going from here? We. We did so much.

I'm like, so before this, we talked a bit about the do not. Are there any other, like, big do nots that we didn't cover, or do we kind of tackle the big ones?

Those are the biggies. If you make sure that you are following the structural principles of motor learning, then chances are you'll stay away from the do nots. So, again, making sure that you have that structure to your target practice. So we're not just randomly picking words. We're going to look for what we call power words. Power words include words a that a lot of children use. Like me, go up, down, right? And then it also is going to take into account what sounds a child has. If they don't have a P, it's hard to work on up. Now, can we stimulate. Can we try and stimulate that? Because I get a lot of questions that say, my child, my client only has, like, you know, four sounds. Where am I going with this? So, first of all, I'll tell you, you'd be surprised with how many simple words or just what we call sound effects you can come up with with even just a few sounds. Even if it's just oh or oh instead of whoa, or for food, when you're, you know, that you're allowed to repeat because it's like, you know, but, you know, even if you just. Instead of peekaboo, you might cover your eyes instead of saying boo, you might go oh, like oh. So what can the child do? Engage them in just repeating those sounds, you know, and learning to go back and forth with you. Like, I say a word of sound, you say a word of sound. We'll get into some of that, like precursors. So, you know, taking what they have instead of just, well, this is a fun word to work on. Oh, you know what? Let me look into my therapy bag and let me just see. Oh, I brought a car today. Oh, car is great. Car is a great word. But if the child doesn't have any of the sounds in the word, you're not going to get anywhere with that. But guess what? If the child has something like, you know, push. A lot of kids might have that P and that sh. Work on push. Push is a great word, right? Work on. Go work on me. Like, send the car to me. I want the car. Be a little creative as to how you use that car. You can play with a car. Kids love cars. But not necessarily for the word car, if a child doesn't have those sounds. So you're choosing in the beginning. You know, people ask, how many words do I work on generally in the very beginning, probably about five words. The reason for that being is because, number one, chances are they don't have a lot of sounds to work with. How many words can I possibly come up with? You know, in my Q and A meetings that I have for my course, therapists challenge me. Can you help me with target selection? And Then they give me, like, three sounds. I'm like, I'm going to do this, I'm going to do this. And it's so much fun. But we usually can come up with four or five words or sound effects or something. So that's why it's small. Number two, we want to have lots of practice, lots of practice of each word because we want them to be able to generalize some verbal communication quickly and feel confident. It builds confidence. This child, chances are, has been through a lot of other therapy before they get to you, and they already feel. They don't feel pretty confident about their skills, which is part of the reason they come in here looking, like, a little sad, you know? Yeah. Want to build us. They want. We want to build their skills as fast as we can. And now it's like, oh, you know, hey, wait a minute. Like, this is something different. I can do this, you know, and then that's.

Yeah.

Successful. And success builds rapport. Yeah, right.

And then they want to work more. They want to try more if they feel good about what they're doing. Yeah, right.

And by the way, that in just one more thing to mention about trying when there was. When we're assessing them, when we're working with children, give them credit for trying. So much of it is about the final product, which obviously it's about the final product. And I know you, you know, certainly for orofacial myofunctional therapy, you go through that a lot with your kids. You know, they're not necessarily going to get the skill right away. You know, there's a lot of skills that need to be built up towards being able to suction your tongue properly. Right. And even just being able to lift tongue, you know, pointed to spot. But, hey, I see, I see you trying to move your tongue. I see what you're doing. I see you closing your mouth to try to say, but your voice isn't turning on, but I see what you're doing. Right. And the child feels so good that you're recognizing the trial, the triangle, because it's not only based on, wow, great, you said me. What about that kid that's trying so hard? And they're like, ma e because that drawer's coming down Mai instead of me. Do they not get any credit?

Right. It's like task analyzing it, Giving them credit for each step that gets you to that end result. And I think that's. They're children, right? They. They inherently want to do good. They want to, you know, most children want to please the adults. And really want success. And I think that it then falls on us to make them feel successful, even while we identify things that we're still working towards. So I love that you kind of broke that down like that with some examples.

And, in fact, yesterday I was working with one of my kiddos. She actually came to me for myofunctional therapy and some arctic issues. But we are onto the speech sound part. But she does have some other comorbidities, so it's not that simple as well. Once we finish the myofunctional therapy, the sounds were easy. Not so much because of some hearing issues and some motor planning issues. And she's the child that will. I mean, this kid wants to please to no end. She comes back every week, her homework is done, and when I say done, it was done. She's like, she cried last week. When she couldn't come because she had strep throat and she couldn't come to see me, she cried. So she's like, I mean, I just. I can't. I love this child so much. And I was a little hard on her yesterday because she kind of wasn't following. And we were trying to work on our L's, and they were. She was just. I don't know, it was just like, kind of a little. And at the end, I'm like, oh, my gosh. I gave her a hug. I'm like, I was hard on you today. Like, I was doubling that. You know what? And I, like, went into him like, because I know you can do it. And I, like, I know. But I was like, I had to check in with myself a little bit because I'm like, oh, my God, Lana, where did that come from? You know? And it's like, no, that wasn't it. Okay. No, like, no, no, no, no. Which, by the way, is an appropriate thing when kids don't need as much cueing. We can't say no. Yes. No. Yes. The reason why I was telling her no is because I wanted her to think about why was it no. And that comes into, like, fading cues. How do we feed the cues? This child's been with me a long time. She. And even we have been working on Elle for a bit. She knows what she was doing like. Or not doing like, I don't need to keep telling you. Are you sure? You're using your tongue. Are you sure? Yeah. No, that wasn't it. Think about it. Right? I want her to think about it. But I thought.

They solidified on her new habit. Yeah, yeah, yeah.

But, like, towards the end, I'm like, oh my God. You know, it was too much.

I had a question that came through when already we were recording and talking about comorbidities. We didn't really talk about this one specifically, but we. There was a question that asked if. You see. Trying to remember what they said. It was something along the lines of like, do you see like motor disorders elsewhere in the body, commonly with children who have apraxia of speech.

Okay, that's a great question. And that's actually. Yeah, sure. And actually, if you read the literature, you know, the research on apraxia, they'll say that's kind of. When we're looking for discriminative characteristics, we're looking to make that differential diagnosis between that and other disorders. Children with phonological or it's just straight up artic. Most likely, but it's possible. But most likely will not have other motor disorders. Right. Whereas children. I got this the other day in my dm, they said, my clients, the mom told me that the otmpt said that this child has motor apraxia. Gross motor, fine motor apraxia. So more likely this child has speech apraxia even though he's only 19 months old. Because we. She actually is in my course right now. We were going back and forth and I was, you know, trying to help her out with this and, you know, what do I do with this little guy? You know, the mom is like convinced he has a proxy of speech and the otmpt kind of let her down that direction. And they probably. Right. You know, they're looking at the body and saying this child has motor movement difficulty throughout his body. It's likely that if he doesn't have any words at 19 months old, difficulty imitating sounds and words, and he has other movement problems in his body. Yeah, yeah, makes sense. These might be your. Your without, of course, let's say a firm diagnosis. But these might be your kids that like my. My 15 year old. I can say it because he was my kid. Not a clinical term, but he was klutzy, very klutzy. And my neighbors didn't want him anywhere near their front stoop because chances are he would fall and they would need to use their house insurance policy. You know, and he was 4 years old and still fall. Falling. Right. He couldn't jump off the ground at 4 years old. The average 2 year old can get himself off the ground. He couldn't figure it out. I mean, we have videos. We laugh at it now. It's too cute. He's like bending his knees and like, willing his body to try to, like, sail off the ground. And like, he just could not combine those movements together. By the way, speech difficulty wasn't his problem at all. I mean, by the way, he ended up with a tongue tie release. That's another podcast. But even though I couldn't nurse him as a baby. Okay, couldn't nurse him as a baby. Felt terrible about it. Tongue tie was first merging as like, I thought maybe, you know, but just gave it up. Guess what, people? He didn't do that well with a bottle either. Surprise, surprise. Yeah, another day. But I ended up having his tongue tie release. He was getting myofunctional therapy, and he does have, like a little bit of a lisp. You know, those kind of errors. But not. No apraxia of speech. None. He firmly. All his milestones came in. He was. I actually kept track of every single word that he said at what age, because I was a speech therapist at that point where I wasn't with my other children. And he had 50 words at 18 months old, like, classic. You know, you look at the developmental charts and like, he was right there.

Okay.

So, I mean, we remember all the cute things he said. He was great, but motor wise, gross. Motor wise, fine. Motor wise. Even today, by the way. And he had years of PTO T. He told me today he's going in for his English midterm, probably around now. Let's pray. And he said, mom, my hand is going to hurt at the end of the day. Now, I know it's a lot of writing and most kids hands will hurt, but for him, it's really a challenge. Yeah, he does get extra time. He does have an IEP and he gives him extra time. And he's like, ma, that's the only test I need extra time on. It's very telling. Very telling. He's still a clumsy kid. He walks down the stairs. I work in my basement in my home, so I know who's coming down the stairs. I hear it from the second floor to the first floor. And he does this thing going thump, thump, thump, thump, thump, thump, thump, thump. He's not really alternating his feet properly at 15 years old. Yeah. So with that said, we have some kids that have the comorbidity of motor planning difficulties throughout the body and motor planning of speech. Right. Or we have kids that have motor planning of speech and don't have any issues in the rest of the body. I've seen that. And I see kids like my son, who has even now challenges motor Wise, but did not have apraxia speech. But when we see it in the body and the child is having trouble with speech, let's take that into consideration. Like, let's put that on the list of. That might be helping us, aiding us in that diagnosis. Yeah. And just in general about comorbidities. I treat a lot of children with comorbidities because I'm PROM certified. A lot of parents with children with children with autism, they look me up on the prom website. I get a lot of my clients to them. People ask me, is it worth it to become PROM certified? Yes, Because I love it anyway. But I got a lot of my private clients through the PROMPT website. So that's, you know, a plus in and of itself, you know. Yeah, yeah, certainly that's how I really built up my private practice that way. And now people find me, you know, people find me mostly word of mouth now. But so when we're talking about comorbidities, we see, as I mentioned before, lots of children with autism, lots of children with down syndrome. I actually saw a video the other day. I follow a mom with a child with down syndrome in my community. He is, I think, 13 or 14 years old, always very verbal. She puts out videos of him. He's adorable, bright, you know, saying the cutest things. But I've always noticed that it's very hard to understand him. But I, I never volunteer information. You know, I assume this mother knows about her child's needs. I'm not going to volunteer. You know, she can look it up. You know, he's getting therapy in school. It's not my business. But she mentioned how difficult it is to understand him sometimes. So I'm like, okay, let me jump in. So I said, look, I told her I don't reach out for people unless they ask for advice. But I just wanted you to know it's possible. And I'm watching his movements and I explained to her why I think he may have apraxia speech. And you may want to look into that. If you want any more information, I'm here for you, you know, so certainly children with down syndrome. Actually, my PROM certification was with a child with down syndrome. She's. I stopped seeing her and fun enough. She's coming back to me at about, at 2:30 today to see me because she's going to come back to me for some. She has trouble now in conversational speech, putting it all together.

Yeah.

So she's going to start coming back to me. But we certainly see. And then we see it, of course, in children. And children can have dysarthria and apraxia speech. I get that question a lot. It is difficult sometimes to discriminate between the two. And we don't always know everything right away. And sometimes as we work with the child, we see, you know, that it's this or that. But, you know, certainly children with dysarthria may need some more oral motor work, maybe some feeding work, that kind of therapy. But we, I see children with various genetic disorders, rare chromosomal abnormalities that just, they really benefit from a motor speech approach. You know, whether or not it's like typical apraxia. No, but it doesn't harm them. I have kids doing really well, you know.

Well, I think that's key too. Right. And thinks we're so trained in society to seek a diagnosis. And I think also obviously insurance, very insurance driven in a lot of cases. And I think parents just want answers. So not knocking the diagnosis, but I think, you know, one of my biggest stances is just as a therapist has always been, I'm not treating the diagnosis per se. I'm treating the child in front of me and how they present. I'm treating them based on their strengths and on their areas of need. And so if we have tools in our toolbox that can help us help this child, if we can kind of get away from this cookie cutter, like, oh, check the box, they have this diagnosis. And yeah, that doesn't tell us how that child's going to respond to different therapeutic approaches. Like, like you were saying, like, you use, you know, dtc, you use prompts that not all kids like you on their face. Some respond better to, you know, imitation type of like visualization and different types of cueing and stuff than others. And so I think that regardless, right. Of how niche you are, like whether you're doing pediatric feeding or you're working with speech, you know, sand to sort of disorders or CIS or mayo or whatever. You know, I think we have to always just kind of go back to like, who is sitting in front of us? Why are they here? What's their concern? What are they responding best to and how can we build on that? And so I love. Because I feel like that's a lot of what you've. You've shared. And again, yeah, you know, that diagnosis is important for various reasons. And there again are going to be comorbidities in a lot of cases. We're going to have kids with more than one thing going on. And sometimes it doesn't come out until later when we've Been working with them. And so I always try to tell parents too. It's like part of that dynamic therapeutic process as we get to know the child and how, you know, we may be working together for a while. And we go, I think we need an ote. Valerie. No, I think there's some other stuff going on here that we could work on, you know, and it's. As an early clinician, it's a process.

You know, it's a process. And I've heard other people on Instagram speak about this, about, you know, we're taught to have this need that when we do this one hour assessment that we're going to have all. I mean, no, absolutely not. Especially when we're dealing with this young population, you know, that I deal with. I mean, how can we. And if. And I, yeah, I say this is what I know today. Yeah.

I would say it makes newer clinicians so uncomfortable. Especially like when we, when we're talking about feeding therapy for them not to have all the answers on day one. And I'm like, I very rarely will check off all the boxes or go through the entire eval. Like, I'm. It's a guiding light in my head. It's a guiding checklist, but it's not something that, you know, we're recording. I'll go back and fill it out later or I'll fill it out after they leave. I'm really using it to help gather information and open a conversation with the parents so that we can get more information and we can kind of glean, like, why are they here? Where are we headed? What is a child really succeeding with and what, you know, where, like, where do we go next? Right. And then we definitely will try things, but it's. I always try to tell everyone. It is that ongoing process and that process word like you highlighted is so key. You're. If you're getting all your answers in the first session, you're doing something wrong. I mean, it's not, it's. That's not. You're not, you're missing something.

Right. You might, you might be making assumptions, you know. Oh, that's true.

Yeah.

It's just one more thing because I know we're running out of time, but it's so interesting because I actually sent a child from another therapist and he comes in here and he was 4 years old and I started asking him to repeat words. And of course I must have picked the words that he just knew perfectly. And he's just doing great. And I'm like, this kid doesn't have apraxia. And I even said it out loud. I said it out loud. The mother's sitting here. I was five minutes into the assessment and I'm like, well, 20 minutes into the assessment. I wanted to eat those words really fast. And I was, I was like, I happens to be just, you know, it wasn't having an easy day that day. It was like at the end of a very long day and I wasn't doing so well and I, I just so jumped to a conclusion that was ridiculous, like unprofessional almost, you know, and by the end of the assessment, I'm like, I really said to the mom, I like, obviously jumped to conclusions and I just like, you know, I. What did they say? That I ate? What is an expression? You know, I, I just, I was like, I'm, you know, obviously made a mistake and these are the reasons why. I see now why you came to me. And yes, your therapist was spot on. And these are the things we need to work on. But let's not worry, right?

It happens.

And let's also just, let's not worry. And I know it's hard for, for new therapists because I still feel that way sometimes. Today I want to give the parent definite answers. I want. But it's okay to say this is an ongoing, it's a dynamic process and let's give it a little time. Yeah. Yeah. So.

Well, this, this has been amazing, Alana. Thank you so much. I know that everyone can find you on Instagram at bondrspeech. Tell us, where can they find you? If you mentioned that you've got blog posts, articles, you've got your free target selection handout.

If you're interested in any of that, we could link it in the show notes, but my website, bondarspeech.com b o n d a r speech.com right away, when you go on, it will have you link up to that free target selection handout and then there's a menu. There's blog posts. I have. Oh, I have all the articles on there. There's an article tab. Just click on the articles of the Principles of Motor Learning, dttc. Why we shouldn't use end zones for Apraxia. Like, it's all there. Everything I mentioned today, all the articles are there. What else is on there? Oh, I have loads of blog posts and courses too. Yes, all my courses are on there. Yes, yes, yes. All the information to my courses. I do have a peer in course as well. If anybody's listening that wants to find out more about that and you're welcome to DM me on Instagram. I, I'm a little addicted to my Instagram, so I usually answer pretty quickly. I made up, I made a resolution last night with my grown daughter that we are going to try to stop touching our phone so much. So it might, I'm doing the same. Yeah, it might take me like an hour instead of two minutes to answer you, but I will get back to you.

I started leaving my phone. I've like started charging my phone at dinner time so it's like in a drawer away from like the dinner table. I've started like at bedtime, like while my kids are going to sleep. I'll allow myself to like put headphones in and like listen and like watch Netflix. But I'm trying not to be on like Instagram because That's just a three hour time suck. And I'm like, it's 11pm how did it become 11? I don't know.

I know, right?

How did that happen? Oh, this behavior. Right. Well, this is amazing.

What happened? Well, all you have to do is look at your screen time, which Apple will be very happy to tell you exactly where you're spending your time and then you will. You'll be embarrassed.

Yeah.

Yeah. Thank you so much, Ali. This was so much fun. Have a great day. Bye. Bye.

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